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og4�iN• SAN JOAQUIN COUNTY <br /> L• ' ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> w� < SITE MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.s' ov.or /ehd <br /> <(FoaN WELL & BORING PERMIT APPLICATION HECEIVED <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MAR 0 7 2011 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Dep pFOpNNMEECN�TcAt�LatH+�EoA,LTH <br /> Site Location 3515 1v CWY DY— Cross Street tA'Do A.-0>2City S'�OG� Zip S2- Affl%C"'-O�rlF* <br /> Prope 00 <br /> Owner -//I��OTJ ``\\ Address-Pb pj [ 4169 City1�111. IN Zip�1c�-2,t'O Phone <br /> C-57 Contrac or Io VIPC1�Vv1 1I, Address CL SO 1�61.LSP_ City VVV&Vti NIP`/ Lic�Z Phone C c> <br /> ConsultanVSub Cntrr 11 ke& )Address tCtUlL(.ot e J 2Y5rd•2-_ City SDNDWICAL_ Lic Phone 404 -435=11.Sra-o <br /> Billable Party Address City Zip Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> WELL IDs -2 - - -S - - - - <br /> OTHERIDs -\Si=L6. CSS-\ . -1.Wa . -1-t _-2-0, >�1 _ •» <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS� , <br /> _❑MONITORING IN HOLLOW STEM DIA.OF BOREHOLE t t rr ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> -49 EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL QQ PVC ❑ OTHER <br /> —0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL"' I S r TREMIE TYPE TO BE USED: IC AUGERS 0 HOSE Id PIPE <br /> ❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes Pa No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> INJECTION(.e.Air Spam.Omne)❑HAND AUGER GROUT SPECIFICATIONS !jJrL IrtPOLilrn <br /> _0 OTHER: ❑OTHER: APPROX.BORING DEPTH o>_I. 7 aBOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR ING No Yes:C sl Dia: Ca ' g Depth: a d Dia: <br /> COMMENTS: $ A t U <br /> NOTE: OFF TE WELLS&BORINGS RE UIRE ACCESS AG EMENTS OR NCROAC ENT RMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OF WELL(S)TO BE DESTROYED ElOVER-BOREDIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and all applicable California laws. / ( ,I, q_.. <br /> Signed y cf V�A..X�-A-� Title/Company (--se-CA r7� S� C \P- t 1 <br /> Print Name L.J 1A rWi I i dJ S Date _J-y.-1 I <br /> �J� DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SSITE ADDRESS JzrS'nLn at.M <br /> WORK PLAN DATED 519 to <br /> APPLICATION ACCEPTED BY4jjCAk_� DATE P§UED fU e2QU AREA�� <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE // <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC At <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> //�� 4 REQUEST PSR# <br /> O $122x2.9.. 0? 917 Ste-/ > 9 d9u SRW6ZIOL <br /> 03 3S-(o 6 r. RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 0728/10 WELL PERMIT APP <br />